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BLF Fulfilling Lives:
Supporting People with
Multiple and Complex Needs
South East Partnership
• Brighton, Eastbourne and Hastings has been identified as
one of 12 areas nationally, in which the BLF has invested.
• To make what already exists work better for people with
Multiple and Complex Needs – through systems change
and innovative short term interventions
• To bring about lasting change in how existing services
work with people with multiple and complex needs
BLF Fulfilling Lives
Our project will work on two levels: an immediate level - working directly with the
people who are most in need of help right now, and on a lasting level - changing
systems to enable people with multiple and complex needs to receive the right
support, at the right time.
We will work with:
• Those who are most invisible to services: unable to access existing services –
whether because they need thorough preparation and planning work to do so,
including specialist interventions, or because services are unable to meet their needs
(for example, having access criteria which exclude them)
• Those who are most visible: clients who are accessing numerous services, numerous
times, but insufficient co-ordination and inappropriate and erratic interventions are
leaving needs unaddressed and recovery unachieved
Core Group Members
Statutory sector reps:
Hastings Borough Council
Eastbourne Borough Council
Brighton and Hove City Council
East Sussex County Council
Voluntary sector reps:
BHT Sussex
Sanctuary Supported Living
Southdown Housing Association
Sussex Central YMCA
Sussex Oakleaf
Equalities and Diversity rep: Brighton Women’s Centre
Homeless Link
Partner Agencies Involved
The Project Model
To address the priority issues of people with multiple and complex needs (MCN), as
identified by service users and services, we have developed the following delivery
A team in each area, made up of:
– An Area Lead
– A Service Improvement Officer focusing on systems change
– 2 Specialist Workers focusing on specific, identified priority issues :
1 Specialist Worker (Women) & 1 Specialist Worker Dual Diagnosis
– Project Consultants assisting with project development and delivery
– Peer mentors and buddies to support service users in their recovery journey
eg: support attending appointments, training and activities
The Project Model
Each of the 3 teams will undertake new interventions/pilots/ways of working with
the client group
6 specialist posts (2 in each geographical location) will work with service users on a
targeted one-to-one basis, all of whom will be those with the most complex needs
The team of workers will co-ordinate all services involved with each individual
client and work pro-actively and creatively to ensure clients are able to navigate
and access the services they need, and can remain engaged.
The Project Model: Specialists
Specialist Workers will work directly with clients. For the first two years of the
Project our consultation with service users has led us to prioritise the following
– Dual diagnosis work with people with multiple and complex needs
– Work with vulnerable women with multiple and complex needs, including
women with multiple children in care, women involved in repeat
violent/abusive relationships
Caseloads will remain small and manageable and completely targeted to those
who are the hardest to reach, living highly chaotic lives with the most complex and
entrenched problems.
Posts may change during the programme, as will post holders, and the employing
The Project Model:
Service and Role Reviews
Services/roles will undergo a process of review and evaluation each year, leading
to changes in design and delivery to better meet the needs of this client group.
Changes may include opening times, access criteria, exclusion decisions, locations,
co-ordinated referral processes etc..
We will link these reviews to the work of the Specialist Posts
In each of the 3 geographical areas 2 posts will lead on this work; the Area Lead
and the Service Improvement Officer (Systems Change)
Service users and ex-service users will be centrally involved in this process,
particularly through the work of the Project Consultants and the Service User
Our Outcomes
• People with multiple and complex needs,
previously not engaging well with services, selfreport that changes in delivery have had a
positive impact on them managing their lives, as
a result of them being accessible, targeted and
better coordinated
• Service users will directly influence
commissioning processes, priorities and decisions
Our Outcomes
• Services and roles will undergo a process of review
and evaluation each year, leading to lasting change in
design and delivery, to better meet the needs of
service users
• The project will achieve long term improvements in
systems, commissioning and policy through
improved outcomes measurement, evaluation and
shared learning
Systems Change
From the outset of the Fulfilling Lives: Supporting People with
Multiple and Complex Needs Programme being introduced, systems
change was integral to achieve the long term outcomes the
programme is aiming to achieve.
• We are aiming to bring about a system that can achieve lasting
positive impact on the lives of people with multiple and complex
needs. This will require fundamental changes, many of which will
be discovered over the lifetime of the project.
• There are also, however, changes needed that are already apparent,
and well evidenced by service users, which this project will explore,
research and find ways to implement, and these include the
following principles:
Systems Change
• One shared data system
• One shared referral and assessment process.
• Service users and panels included in all policy and
commissioning decisions.
• Peer support embedded in all provision
• Shared training and skills standards across all sectors
• Service user assured Quality Mark
• Flexible access criteria, service thresholds, operating hours and
Systems Change
• Outreach and assertive engagement
• No service user to be left without appropriate support
• Personalised, individualised interventions
• Immediate crisis response and fast tracking
• Alignment of commissioning cycles
• Shared outcomes system
• Culture of continuous improvement and learning
• Implementation of evidenced national recommendations, e.g.
No Wrong Door, No Second Night Out